Tièche et al. BMC Health Services Research (2016) 16:373 DOI 10.1186/s12913-016-1647-4
RESEARCH ARTICLE
Open Access
Patient satisfaction is biased by renovations to the interior of a primary care office: a pretest-posttest assessment Raphaël Tièche1, Bruno R. da Costa2 and Sven Streit2*
Abstract Background: Measuring quality of care is essential to improve primary care. Quality of primary care for patients is usually assessed by patient satisfaction questionnaires. However, patients may not be able to judge quality of care without also reflecting their perception of the environment. We determined the effect that redesigning a primary care office had on patient satisfaction. We hypothesized that renovating the interior would make patients more satisfied with the quality of medical care. Methods: We performed a Pretest-Posttest analysis in a recently renovated single-practice primary care office in Grenchen, Switzerland. Before and after renovation, we distributed a questionnaire to assess patient satisfaction in four domains. We chose a Likert scale (1 = very poor to 6 = very good), and 12 quality indicators, and included two consecutive samples of patients presenting at the primary care office before (n = 153) and after (n = 153) interior design renovation. Results: Response rate was high (overall 85 %). The sample was similar to the enlisted patient collective, but the sample population was older (60 years) than the collective (52 years). Patient satisfaction was higher for all domains after the office was renovated (p < 0.01–0.001). Results did not change when we included potential confounders in the multivariable model (p < 0.01). Conclusions: Renovating the interior of a primary care office was associated with improved patient satisfaction, including satisfaction in domains otherwise unchanged. Physician skills and patient satisfaction sometimes depend on surrounding factors that may bias the ability of patients to assess the quality of medical care. These biases should be taken into account when quality assessment instruments are designed for patients. Keywords: Patient satisfaction, Primary care, Quality of care, and Change of appearance Abbreviations: CI, Confidence Interval; GP, General Practitioners; MFE, Swiss Occupational Union of General Practitioners and Pediatricans; SD, Standard Deviation
Background Measuring quality of care is essential to improve primary care, but measuring quality of care is difficult and there is, as yet, no established method to effectively assess quality [1]. We cannot know what to change unless we know what is wrong. In Switzerland, the concept of quality in primary care is being elaborated by a task force established by the occupational union (MFE) of * Correspondence: [email protected] 2 Institute of Primary Health Care (BIHAM), University of Bern, Gesellschaftsstrasse 49, 3012 Bern, Switzerland Full list of author information is available at the end of the article
general practitioners (GPs) [2]. The concept includes four topics: quality circles (working groups of GPs), patients, health care providers, and the next generation of GPs. Quality of primary care for patients is usually assessed by patient questionnaires and comparative benchmarks of scores for GP offices, but questionnaires are designed to measure the patient’s subjective perception of quality. Conclusions based solely on subjective quality of care assessments by patients may bias results, and limit their usefulness as benchmarks for primary care offices. For example, a recent study shows how difficult it is to
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tièche et al. BMC Health Services Research (2016) 16:373
separate the role of the physical environment from the effect of social forces on patient wellbeing [3]. An earlier UK study found that upgrading the primary care environment can increase patient satisfaction [4]. This and similar studies found that environmental upgrades also improve patient perceptions about the health care they receive [5, 6]. Patients may not be able to judge quality of care without also reflecting their perception of the environment. On the other hand, Gosling et al. conducted two studies that suggest that observer impressions are often accurate and rely on valid environmental clues to correctly judge the characteristics of staff and other room occupants [7]. Since patients are usually not well-informed about standards of practice, and because they do not have a medical education, they often judge a doctor’s performance based on the personality of the physician, and the physical environment [8]. Patients may believe that a redesign reflects the provider’s desire to care for their wellbeing, and may then assume that the provider puts the same energy into providing medical services. This may be why attractive and comfortable waiting rooms, and good lighting can result in higher quality of care assessments from patients [9]. Patient assessment of quality of care may not describe accurately the standards of the medical practitioners who treat them. We hypothesized that upgrading the interior design of an office would improve patient perceptions of quality of care, absent any other changes. We tested our hypothesis
Page 2 of 6
with pre- and post-renovation questionnaires to measure the amount that renovating a GP office changed patient satisfaction in other dimensions, like quality of treatment or physician reliability.
Methods Study design
This is an observational study with a pretest-posttest assessment design. Setting
Our study was conducted in the group practice of two GPs in Grenchen, a city with 17,000 inhabitants, located in the countryside in the northwestern part of Switzerland. The GP office was founded in 1981 by the senior GP; the junior GP joined the practice in 2013. Patients in Switzerland are free to choose their GP. Two out of three patients at office have seen their physicians there for more than 5 years. The patients who visited the office within the last 2 years were mostly women (53 %); mean age was 52 years. Most patients (80 %) speak German. Population and intervention
For 6 weeks, from June 23 until August 8, 2014, the practice was renovated. The entry hall, the reception area, the laboratory where patients give blood, the waiting room, the staff room, and the pharmacy were refurnished (Fig. 1). The consultation rooms were not changed. No new working processes or instruments
Fig. 1 Panels a, b, and c display the GP office before (left side) and after renovation (right side). a reception, b waiting room, c laboratory. We received consent to publish the pictures from all people on (a)
Tièche et al. BMC Health Services Research (2016) 16:373
were introduced during the observation period. Both GPs continued working the same number of days before and after renovation (senior GP 3 days/week, junior GP 4 days/week). A medical assistant who had been working 3 days/week left the team after the renovation; four medical assistants remained (3 working full time, 1 working 2.5 days/week). We performed a 1-week pilot study to assess feasibility and reply rate before the renovations began. On April 7, 2014, while patients were waiting to consult the doctor, a medical assistant assured patients of anonymity and asked for oral consent before she distributed survey questionnaires (Additional file 1). The GPs did not distribute the questionnaire or refer to it during consultation. The questionnaire was offered to all Germanspeaking patients aged >18 years, in order of arrival, until all 180 questionnaires were handed out. Patients could fill out the forms before or after they saw the doctor. After the consultation, and before they left the office, a medical assistant asked patients if they had completed the questionnaire and collected them. The week after renovation, a medical assistant distributed another 180 questionnaires, using the same strategy as for the first. The second questionnaire was the same as the first, but was printed on yellow paper, so patients who had filled it out in the first round would not think they were being given an identical questionnaire. Patients were told this questionnaire would be for post-assessment after renovation and to fill out the questionnaire only if they had already attended the office prior to renovation (>2 months). For post-assessment patients attending the office for
RESEARCH ARTICLE
Open Access
Patient satisfaction is biased by renovations to the interior of a primary care office: a pretest-posttest assessment Raphaël Tièche1, Bruno R. da Costa2 and Sven Streit2*
Abstract Background: Measuring quality of care is essential to improve primary care. Quality of primary care for patients is usually assessed by patient satisfaction questionnaires. However, patients may not be able to judge quality of care without also reflecting their perception of the environment. We determined the effect that redesigning a primary care office had on patient satisfaction. We hypothesized that renovating the interior would make patients more satisfied with the quality of medical care. Methods: We performed a Pretest-Posttest analysis in a recently renovated single-practice primary care office in Grenchen, Switzerland. Before and after renovation, we distributed a questionnaire to assess patient satisfaction in four domains. We chose a Likert scale (1 = very poor to 6 = very good), and 12 quality indicators, and included two consecutive samples of patients presenting at the primary care office before (n = 153) and after (n = 153) interior design renovation. Results: Response rate was high (overall 85 %). The sample was similar to the enlisted patient collective, but the sample population was older (60 years) than the collective (52 years). Patient satisfaction was higher for all domains after the office was renovated (p < 0.01–0.001). Results did not change when we included potential confounders in the multivariable model (p < 0.01). Conclusions: Renovating the interior of a primary care office was associated with improved patient satisfaction, including satisfaction in domains otherwise unchanged. Physician skills and patient satisfaction sometimes depend on surrounding factors that may bias the ability of patients to assess the quality of medical care. These biases should be taken into account when quality assessment instruments are designed for patients. Keywords: Patient satisfaction, Primary care, Quality of care, and Change of appearance Abbreviations: CI, Confidence Interval; GP, General Practitioners; MFE, Swiss Occupational Union of General Practitioners and Pediatricans; SD, Standard Deviation
Background Measuring quality of care is essential to improve primary care, but measuring quality of care is difficult and there is, as yet, no established method to effectively assess quality [1]. We cannot know what to change unless we know what is wrong. In Switzerland, the concept of quality in primary care is being elaborated by a task force established by the occupational union (MFE) of * Correspondence: [email protected] 2 Institute of Primary Health Care (BIHAM), University of Bern, Gesellschaftsstrasse 49, 3012 Bern, Switzerland Full list of author information is available at the end of the article
general practitioners (GPs) [2]. The concept includes four topics: quality circles (working groups of GPs), patients, health care providers, and the next generation of GPs. Quality of primary care for patients is usually assessed by patient questionnaires and comparative benchmarks of scores for GP offices, but questionnaires are designed to measure the patient’s subjective perception of quality. Conclusions based solely on subjective quality of care assessments by patients may bias results, and limit their usefulness as benchmarks for primary care offices. For example, a recent study shows how difficult it is to
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tièche et al. BMC Health Services Research (2016) 16:373
separate the role of the physical environment from the effect of social forces on patient wellbeing [3]. An earlier UK study found that upgrading the primary care environment can increase patient satisfaction [4]. This and similar studies found that environmental upgrades also improve patient perceptions about the health care they receive [5, 6]. Patients may not be able to judge quality of care without also reflecting their perception of the environment. On the other hand, Gosling et al. conducted two studies that suggest that observer impressions are often accurate and rely on valid environmental clues to correctly judge the characteristics of staff and other room occupants [7]. Since patients are usually not well-informed about standards of practice, and because they do not have a medical education, they often judge a doctor’s performance based on the personality of the physician, and the physical environment [8]. Patients may believe that a redesign reflects the provider’s desire to care for their wellbeing, and may then assume that the provider puts the same energy into providing medical services. This may be why attractive and comfortable waiting rooms, and good lighting can result in higher quality of care assessments from patients [9]. Patient assessment of quality of care may not describe accurately the standards of the medical practitioners who treat them. We hypothesized that upgrading the interior design of an office would improve patient perceptions of quality of care, absent any other changes. We tested our hypothesis
Page 2 of 6
with pre- and post-renovation questionnaires to measure the amount that renovating a GP office changed patient satisfaction in other dimensions, like quality of treatment or physician reliability.
Methods Study design
This is an observational study with a pretest-posttest assessment design. Setting
Our study was conducted in the group practice of two GPs in Grenchen, a city with 17,000 inhabitants, located in the countryside in the northwestern part of Switzerland. The GP office was founded in 1981 by the senior GP; the junior GP joined the practice in 2013. Patients in Switzerland are free to choose their GP. Two out of three patients at office have seen their physicians there for more than 5 years. The patients who visited the office within the last 2 years were mostly women (53 %); mean age was 52 years. Most patients (80 %) speak German. Population and intervention
For 6 weeks, from June 23 until August 8, 2014, the practice was renovated. The entry hall, the reception area, the laboratory where patients give blood, the waiting room, the staff room, and the pharmacy were refurnished (Fig. 1). The consultation rooms were not changed. No new working processes or instruments
Fig. 1 Panels a, b, and c display the GP office before (left side) and after renovation (right side). a reception, b waiting room, c laboratory. We received consent to publish the pictures from all people on (a)
Tièche et al. BMC Health Services Research (2016) 16:373
were introduced during the observation period. Both GPs continued working the same number of days before and after renovation (senior GP 3 days/week, junior GP 4 days/week). A medical assistant who had been working 3 days/week left the team after the renovation; four medical assistants remained (3 working full time, 1 working 2.5 days/week). We performed a 1-week pilot study to assess feasibility and reply rate before the renovations began. On April 7, 2014, while patients were waiting to consult the doctor, a medical assistant assured patients of anonymity and asked for oral consent before she distributed survey questionnaires (Additional file 1). The GPs did not distribute the questionnaire or refer to it during consultation. The questionnaire was offered to all Germanspeaking patients aged >18 years, in order of arrival, until all 180 questionnaires were handed out. Patients could fill out the forms before or after they saw the doctor. After the consultation, and before they left the office, a medical assistant asked patients if they had completed the questionnaire and collected them. The week after renovation, a medical assistant distributed another 180 questionnaires, using the same strategy as for the first. The second questionnaire was the same as the first, but was printed on yellow paper, so patients who had filled it out in the first round would not think they were being given an identical questionnaire. Patients were told this questionnaire would be for post-assessment after renovation and to fill out the questionnaire only if they had already attended the office prior to renovation (>2 months). For post-assessment patients attending the office for
